Risk Management: Physician Prescribing Practices: Pitfalls to Avoid
By: KENT G. HARBISON
December 1992 (As seen in Minnesota Physician)
Prescribing medications is integral to the practice of medicine for most physicians. Writing prescriptions is practically a daily activity for some physicians; for others, prescriptions are written only sporadically. Most patients would consider the prescribing of medications a fundamental part of receiving a doctor's care.
It is not surprising, therefore, that the Minnesota Board of Medical Practice has been looking into physician prescribing practices much more carefully during recent years. In fact, questions concerning prescribing practices constitute a relatively large percentage of all the numerous possible grounds for complaints lodged with the Board of Medical Practice.
Given this development, most Minnesota physicians would be well-served to take the time periodically to evaluate their prescribing practices. The best time to conduct this evaluation, of course, is when there is not urgent reason to do so - sort of a form of preventative medicine. Conducting the self-evaluation after receiving a notice of complaint or letter of inquiry from the Board certainly is helpful but, in some cases, may be too late.
Those physicians who are requested by the board to explain their prescribing activities often ask what standards of conduct the board expects them to follow. The Board itself published a series of specific guidelines in its Fall, 1990 Update newsletter. With the permission of the executive director of the board, this article revisits these guidelines in an effort to inform physicians of the criteria that are likely to be applied when the board evaluates its prescribing practices.
Organized and Complete Records
The Board has identified nine tests, or steps, for measuring the appropriateness of a prescribing activity. Even though many of these tests seem obvious and fundamental, many physicians will find it helpful to know the perspective of the board. Perhaps most important in the application of these standards is the physician's documentation in the patient records. In fact, the organization and completeness of patient records is often a critical is often a critical factor. Disorganized and incomplete or inconsistent records are sometimes seen by the Board as reflecting questionable prescribing practices.
The first of the nine tests is to "start with a diagnosis which is supported by a history and physical, and by the results of an any appropriate tests" before a physician prescribes any kind of medication. Certainly, most physicians would never consider issuing a prescription without first making a diagnosis of the patient's medical condition and needs. The lack of a specific diagnosis underlying a prescription is relatively rare among cases reviewed by the Board. The more common problem is that the diagnosis (and patient's history and physical) is not clearly reflected in the patient's medical records. The Board, not surprisingly, frowns on prescriptions that are not based on specific diagnoses, especially when there is not a supporting written record.
The second step is for the physician to prepare a "treatment plan" that is contained in the records and "which includes the use of appropriate non-addictive modalities" and includes "referrals to appropriate specialists." In other words, the Board wants to know whether a physician who is about to prescribe a particular medication has: (1) first thought about a specific plan of treatment and (2) has consciously considered alternative forms of treatment or consultation prior to embarking on a long-term series of prescriptions.
The third step is for the physician to decide on an objective basis whether "non-addictive modalities" are appropriate. Obviously, the primary reason that the Board focuses on prescribing practices in the first place is to ensure that patients do not become addicted or otherwise chemically dependent as a result of prescriptions that were not closely monitored or used without consideration of other options. In many instances, of course, patients have such severe illnesses or disabilities that even the risk of chemical dependency may be the best of all options, particularly when one considers the productivity of lifestyle of a patient without certain medications over the long-term. Nevertheless, the Board wants reassurance that the other options have been tried unsuccessfully or are not appropriate for other reasons.
For example, would it be appropriate to seek help from a chronic pain clinic, from a psychological evaluation, or perhaps even from surgery? The Board suggests that, if a physician has any doubt about these questions, or any alternative treatment modalities, it never hurts to consider the feasibility of obtaining a chemical dependency evaluation. This is particularly true for patients who have been taking potentially addictive medications over a period of years.
Medication with Dependency Potential
The fourth step in the process is obtaining the "informed consent" of the patient prior to prescribing any medication that has the potential to create dependency problems. The concept of "informed consent" is not new to physicians. It often arises in malpractice cases, when a patient may claim that he or she did not truly understand the risks of a particular procedure or treatment plan at the time it was undertaken. To avoid such problems or misunderstandings regarding prescription programs, the Board suggests that doctors should also explain to their patients the pros and cons of a particular treatment plan when dealing with patients who are about to begin a potentially lengthy series of medications with chemical dependency potential. In the Board's 1990 newsletter regarding this topic, it encouraged physicians to obtain information concerning dependency potential from the drug companies, the Professionals Guide to Patient Drug Facts from Facts and Comparisons and from a variety of AMA publications.
The fifth factor advocated by the Board is to ensure that the patient is not a drug seeker. This is an obvious caveat but not always easy to identify. There are some warning signs that physicians can keep in mind: patient "habitually" loses the prescription; patient begins using up the prescribed medication faster than normal; patient "accidentally" drops the pills into the bathroom toilet each month; patient lives with someone convicted of illicit drug sale; patient claims to have used up the medication but his or her blood test shows no evidence of the drug, etc.
Most physicians are also careful about prescribing or refilling prescriptions while on call for patients whose "regular doctor" may be temporarily unavailable. In such circumstances weekend prescriptions should be made only after there has been a personal exam or consultation and an analysis of the patient's medical records, and the dosage should be limited to the amount minimally necessary to last until the next business morning, when the patient can be seen by the "regular doctor."
After prescriptions are issued, the sixth step is to undertake "regular monitoring of the patient." This means requiring the patient to come in for regular exams and appointments and to ensure that this monitoring is reflected in the patient records. The Board will be suspicious of a prescribing practice when the patient charts show that a potentially addictive medication has been prescribed for many months or years, even though there is no documentation of any exams during this time period. It is awkward for a physician sitting before the Board's Complaint Review Committee to explain why he or she has prescribed Tylenol 3 repeatedly for two years without being able to show any documentation that the patient was examined more than once during that period.
Likewise, a physician should be wary of a patient who requests refills or continued prescriptions after having moved "temporarily" to another city. Naturally, when it is clear that the move is temporary and of a very short duration, it may very well be appropriate for the original physician to continue monitoring and prescribing for the patient. On the other hand, when the relocation begins to last for many months and there is clearly other medical facilities more convenient to the relocated patient, the original physician should seriously consider severing the relationship and transferring the patient's files to a doctor who is more accessible.
Controlling the Supply
The seventh step advocated by the Board is for the physician to be sure that he or she is the person "in control of the supply of the drug." There are at least three ways to maintain this control. First, the physician, not the patient, must ultimately be the person to decide which medication is to be used and in what amounts. The choice of drug must be based on professional opinion, which may or may not be consistent with what the patient believes "works best." Second, the physician should require the patient, who is on a long-term medication program, to return on a regular basis as a prerequisite to certain refills. Personal visits are not required for each refill, but the Board considers it good practice to ensure that refills are not automatically continued indefinitely without some kind of visit or exam.
Third, physicians may find it helpful to keep a written record of the cumulative dosage over a period of time and the average daily dosage during the period. This information can more graphically show a physician at any given time the total amount of a particular drug that is being prescribed on a longer-term basis. Without such records, physicians are sometimes startled themselves to find that at the end of a three-year period, the total amount of a particular prescription has reached much greater proportions than the physician had realized.
The eighth "suggestion" from the Board is for the physician to attempt to make some kind of regular contact with a patient's family members. Naturally, this is not possible in may cases, but the Board believes that family members can often provide good information to a physician regarding a patient's compliance with a prescription program and the effects of that program on the patient. Occasionally, this kind of feedback is even more useful than that given by the patient. Indeed, comments from a patient's family members can actually confirm that the treatment and prescription programs set by the doctor have resulted in significant improvement.
The ninth, and final standard used by the Board in evaluating a prescription program is embodied in most of the preceding standards. That is, proper records management is essential. A physician who has appropriately managed a prescription program for a particular patient will, nonetheless, not find great favor with the Board, if that program is not reflected fully in the patient records. As the Board stated in the article appearing in the Fall, 1990 Update:
"It's not what you prescribe, but how well you manage the patient's care, and create a record of that care, that's important."
There are no doubt exceptions to each of the nine steps identified by the Board for measuring the appropriateness of a prescribing practice. There will always be some room for accommodation, because of unique factors such as the type of disability, a patient's age, geographic location, financial access to other options, access to other options, a patient's attitude, etc. Regardless of whether every physician supports literally each of the Board' nine steps, the inescapable fact is that the agency that exercises the licensing and disciplinary control over Minnesota physicians definitely uses these nine standards evaluating prescribing complaints.
These complaints can sometimes come from the patients themselves, sometimes from pharmacists, sometimes from other physicians and increasingly often from third party payors. In fact, many of the Board's investigations regarding prescribing practices originate from reports generated by the Medical Assistance reimbursement program managed by the Minnesota Department of Human Services. These audits, or reports, may spin out a prescribing pattern that looks unusually risk on its face, without the benefit of other information pertaining to the patient's medical needs, history, alternative programs, etc.
Although the relative percentage of prescribing cases presented to the Board in recent years is significant, the actual number of such cases resulting in disciplinary orders has been decreasing, according to H. Leonard Boche, executive director of the Board. In 1990 the Board issued disciplinary orders in 13 prescribing cases; in 1991 there were 16 orders; and thus far in 1992 there have been nine discipline orders in prescribing cases. Of the 16 orders in 1991, seven involved physicians in only two clinics and two were based on criminal convictions.
Finally, when a physician is asked by the Board to respond to questions regarding prescribing practices this does not mean that the Board has already concluded that there is a problem. As described above in this article, many of these "complaints" are simply generated by reports that superficially raise some questions about a particular prescribing program. Typically, the Board's final decisions will be based on the application of the nine standards described in this article.